Naloxone Distribution Through Syringe Service Programs, United States, 2019

Syringe service programs (SSPs) give people who inject drugs access to sterile syringes and other equipment and a safe way to dispose of them. They are a highly successful HIV prevention measure, linked to a 58% reduction in new HIV infections among people who inject drugs. Many have also taken up overdose education and naloxone distribution (OEND) — training laypeople to respond to an overdose and giving them naloxone and instructions for using it. SSPs are well placed to do this: their services are designed to reach people at high risk of having or witnessing an opioid overdose.

In 2013, only 55% of U.S. SSPs offered OEND. A 2019 survey, reported in CDC's MMWR, looked at how far that had come.

The survey

In February 2019, the North America Syringe Exchange Network (NASEN), which has supported SSPs for three decades and keeps a database of them, invited all 342 known SSPs to take an online survey; 263 (77%) responded. Researchers compared naloxone distribution with 2017 opioid overdose deaths in each of the nine U.S. Census divisions, using two measures of "reach": people given naloxone per overdose death, and doses distributed per death.

What they found

Most SSPs now offer naloxone. 247 of 263 (94%) had an OEND program, and 160 of those had started since 2016. Of the 16 without one, four had distributed naloxone before but stopped because of inadequate supply or funding.

Among the 247 programs:

• 77% offered OEND every time they provided syringe services, and 87% gave refills as often as participants asked;
• programs offered OEND a median of 15 of the past 28 days;
• only 12% entered OEND data directly into an electronic system.

The volume was large — and concentrated. In the previous 12 months, 237 programs distributed 702,232 naloxone doses, including refills, to 230,506 people — about 3 doses each. Just 14 programs (6%), spread across six of the nine Census divisions, gave out 10,000 or more doses each, accounting for 54% of all doses. Programs serving more than 1,000 people each reached 81% of all recipients. And 29% of programs had run out of naloxone or had to ration it in the preceding three months.

Syringe service programs implementing overdose education and naloxone distribution over time (MMWR).

Reach varied by region. Reach was highest in the Mountain and West North Central divisions. Programs in the East South Central, Middle Atlantic, New England and South Atlantic divisions had low reach — even though those divisions, along with the East North Central, had some of the highest overdose death rates. East North Central programs distributed many doses per death (24) but reached relatively few people per death (4).

Opioid overdose death rates and the reach of syringe program naloxone distribution by Census division (MMWR).

What it means

There's no agreed target for how much naloxone is enough, but evidence points to scale mattering: in Massachusetts, overdose deaths fell 46% in communities that enrolled more than 100 at-risk people per 100,000 residents in OEND, and in Scotland, deaths fell 62% when the national program distributed 20 times as many naloxone doses as the previous year's overdose deaths.

The authors call for scaling up SSP-based naloxone programs in the East, where overdose death rates are high and reach is low, with adequate resources, staffing and supportive laws — especially as fentanyl in the illegal drug supply has driven overdose rates sharply higher even in places with long-running programs. Ensuring every SSP participant has a steady supply of naloxone, and expanding SSPs nationwide, could help reduce overdose deaths.

Limitations

Some SSPs may be missing from NASEN's database, and the programs that didn't respond tend to be small. Answers were self-reported and some were estimates, and because SSPs work at a much smaller scale than Census divisions, distribution within each division is uneven.

Sources

• Lambdin BH, Bluthenthal RN, Wenger LD, et al. "Overdose Education and Naloxone Distribution Within Syringe Service Programs — United States, 2019," MMWR Vol. 69, No. 33, CDC; a work of the United States government in the public domain. The report lists the highest-reach divisions as Mountain, Pacific and West North Central in its results but Mountain, West and West North Central in its discussion, so only the two it names both times are given here.